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Oregon State Hospital to submit corrective action plan to state, federal regulators

Monday, May 9, 2022

[Oct. 6, 2022 update: View the latest plan of correction here.​]​

Response follows CMS report on deficiencies at OSH's Junction City campus

PORTLAND, Ore. – Administrators at the Oregon State Hospital (OSH) have 10 days to submit a corrective action plan or risk losing certification to be reimbursed for federal Medicare payments after state regulators filed a report that identified a range of supervision and reporting deficiencies at the hospital's Junction City campus.

The findings stem from an inquiry into the supervision of a patient who went on unauthorized leave, known as “elopement," during an outing in the community late last year. However, the investigation's scope broadened after the initial incident uncovered additional deficiencies.

OSH provides psychiatric treatment for adults from throughout the state who need hospital-level mental health treatment. The hospital provides care at two campuses: a main campus in Salem and a second campus at Junction City. The state hospital is eligible to receive federal Medicare and Medicaid payments under Conditions of Participation issued by the federal Centers for Medicare and Medicaid Services (CMS) and, like other health care facilities, must remain in compliance with federal requirements – including meeting state licensing obligations – to continue to receive federal reimbursement.

The federal inquiry focused on operations at the Oregon State Hospital's Junction City location in December 2021 and January 2022. The review was conducted by surveyors in the Health Facility Survey and Certification Program in the Health Care Regulation and Quality Improvement (HRQI) Section, which is part of the Oregon Health Authority's Public Health Division. One of HRQI's primary roles is to conduct reviews of complaints at hospitals and other health care facilities in Oregon on behalf of federal regulators.

The hospital is also a division of OHA. HCRQI regulators conducted the review following standard processes and protocols used in similar investigations into complaints at other psychiatric hospitals and programs in the state.

In their investigation report, HCRQI surveyors identified federal and state compliance issues in several categories reflecting deficiencies under CMS Conditions of Participation. Oregon State Hospital is making the CMS report available to the public as part of its commitment to transparency and ensuring accountability to its patients and their families.

Surveyors cited issues ranging from the lack of a permanent, onsite administrator to manage the Junction City campus on a daily basis, to episodes in which Junction City staff lost visual contact with patients while on outings, to shortcomings in documenting follow-up reviews after patient-to-patient altercations.

Administrators at OSH must submit a corrective action plan to CMS (through state regulators in the HRQI program), by May 15, which marks the 10-day deadline from the date of the federal agency's notification.

State hospital Superintendent Dolly Matteucci said, “Our staff at the Oregon State Hospital want to provide the highest quality care to our patients so they can recover and return to live healthy and productive lives in their communities. We look forward to addressing each of the administrative, documentation and supervision issues highlighted in this report."​

OHA Director Patrick Allen said, “I appreciate the rigor and thoroughness of our state health care regulatory surveyors, who in their role of acting on behalf of CMS, took the opportunity to conduct a broad review of state hospital administrative structures and procedures. The state hospital will act promptly and transparently to fix these gaps."



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